Main symptoms Main symptoms and syndromes in and syndromes in

aarterial rterial hypertensionhypertension

N. BilkevychN. Bilkevych

Arterial hypertension is Arterial hypertension is defined as rising of arterial defined as rising of arterial

blood pressure excess of 140 blood pressure excess of 140 mm Hg systolic one (SBP), mm Hg systolic one (SBP), and/or excess of 90 mm Hg and/or excess of 90 mm Hg

diastolic blood pressure (DBP).diastolic blood pressure (DBP).

EpidemiologyEpidemiology Hypertension is one among the most wide-Hypertension is one among the most wide-

spread among all cardiovascular diseasesspread among all cardiovascular diseases.. 15 – 25 % 15 – 25 % of people in the population of people in the population

have hypertension have hypertension + 15 % + 15 % have bordeline have bordeline hypertensionhypertension..

Primary hypertensionPrimary hypertension occupiesoccupies 80 – 95 % 80 – 95 % of all arterial hypertensions and 1of all arterial hypertensions and 10 % 0 % of of them are secondary hypertensions.them are secondary hypertensions.

Поширеність основних серцево-судинних захворювань в Україні

16%28%

41%

15%

ЦВЗ - цереброваскулярні захворювання ІХС - ішемічна хвороба серцяГХ - гіпертонічна хвороба

Mortality because of AH Mortality because of AH according to its degreeaccording to its degree

Presentation of AH in the Presentation of AH in the population according to usage of population according to usage of

fats in the dietfats in the diet

Essential, primary, or idiopathic Essential, primary, or idiopathic hypertension is defined as high BP in hypertension is defined as high BP in which secondary causes forms are not which secondary causes forms are not

presentpresent Aetiology and pathogenesis:Aetiology and pathogenesis: Overstrain of the central nervous system Overstrain of the central nervous system nervous-functional disorder in regulation of nervous-functional disorder in regulation of

the vascular tone the vascular tone vegetative-endocrine disorders and changes vegetative-endocrine disorders and changes

in the renal regulation of the vascular tonein the renal regulation of the vascular tone vasopressor adrenal reaction by which vasopressor adrenal reaction by which

arterioles of internal organs are narrowed arterioles of internal organs are narrowed production of rennin, stimulation of rennin-production of rennin, stimulation of rennin-

angiotensin system and systemic angiotensin system and systemic vasodilatationvasodilatation

activation of aldosterone secretion.activation of aldosterone secretion.

Pathogenesis Pathogenesis of AHof AH

Risk-factorsRisk-factorsNon-modified Age Genetics and family history Sex( male or female) Family and personal history of hyperlipidaemia Family and personal history of diabetes Race

Modified Cigarette smoking, alkohol Environment (stress, sedentary lifestyle) Weight (obesity and metabolic syndrome) Dietary habits (high alcohol intake, high sodium intake, low

potassium intake) Hypodinamia Personality

ClassificationClassification According to According to

blood pressureblood pressure::- - normalnormal: : SBPSBP << 130 130

andand DBPDBP << 90 90 mm mm of Hgof Hg. .

- - Bordeline Bordeline hypertensionhypertension: : SBPSBP = 140-160 = 140-160 andand DBPDBP = 90-95 = 90-95 mm of Hgmm of Hg;;

- Arterial Arterial hypertension:hypertension: SBPSBP >> 1 1660 0 andand DBPDBP >> 9955 mm of Hgmm of Hg. .

SBPSBP DBPDBP

OptimalOptimal <120<120 <80<80

NormalNormal <130<130 <85<85

High High normalnormal

130-139130-139 85-8985-89

HyperteHypertensionnsion

I (mild)I (mild) 140-159140-159 90-9990-99

II(moderaII(moderate)te)

160-179160-179 100-109100-109

III III (severe)(severe)

>180>180 >110>110

Isolated Isolated systolicsystolic

>140>140 <90<90

Level of BP in mild, moderate Level of BP in mild, moderate and severe AHand severe AH

WHPO classification of arterial WHPO classification of arterial hypertension (1993)hypertension (1993)

Stage I – no evident signs of target organ damageStage I – no evident signs of target organ damage

Stage II – presence of at least one of the following Stage II – presence of at least one of the following signs of target organ damage:signs of target organ damage:

Heart:Heart: LVH (diagnosed radiologically, on ECG or by Echocardiography) LVH (diagnosed radiologically, on ECG or by Echocardiography) Retina:Retina: generalized or focal narrowing of retinal arteries generalized or focal narrowing of retinal arteries Kidney:Kidney: microalbuminurua, proteinuria, creatinine<2mg/dl (176 µmol/l) microalbuminurua, proteinuria, creatinine<2mg/dl (176 µmol/l) Vessels:Vessels: increased IMT or plaques in carotid, iliac, or femoral arteries increased IMT or plaques in carotid, iliac, or femoral arteries

• Stage III – signs of severe target organ damage:Stage III – signs of severe target organ damage:

Heart:Heart: angina pectoris, myocardial infarction, heart failure angina pectoris, myocardial infarction, heart failure Brain:Brain: stroke, TIA, vascular dementia stroke, TIA, vascular dementia Retina:Retina: haemorrhages, exudates, papilloedema haemorrhages, exudates, papilloedema Kidney:Kidney: renal insufficiency (creatinine>2mg/ml) renal insufficiency (creatinine>2mg/ml) Vessels:Vessels: dissecting aortic aneurysm, symptomatic occlusive peripheral dissecting aortic aneurysm, symptomatic occlusive peripheral

arterial diseasearterial disease

Clinical manifestationClinical manifestation The main objective sign of The main objective sign of

the disease is elevated the disease is elevated arterial pressure (over arterial pressure (over 140/90 mm Hg) . Blood 140/90 mm Hg) . Blood pressure is liable in early pressure is liable in early stage of the disease but stage of the disease but later stabilizes. later stabilizes.

Manifestation of Manifestation of hypertension hypertension depends ondepends on::

Course of the Course of the diseasedisease

Its stageIts stage;; Presence of Presence of

complications and complications and crisescrises;;

Pathogenetic variantPathogenetic variant ((benign and maligantbenign and maligant).).

I stageI stageComplaintsComplaints:: may be abcentmay be abcent patients would usually complain of neurotic patients would usually complain of neurotic

disorders: general weakness, impaired work disorders: general weakness, impaired work capacity, inability to concentrate during work, capacity, inability to concentrate during work, deranged sleep, trancient headache, e feeling of deranged sleep, trancient headache, e feeling of heaviness in the heart, vertigo, noise in the ears, heaviness in the heart, vertigo, noise in the ears, and sometimes palpitation, hain in heart region. and sometimes palpitation, hain in heart region. Exertional dyspnoea develops later.Exertional dyspnoea develops later.

Data of objective examinationData of objective examination Signs if lesions of internal organs are abcentSigns if lesions of internal organs are abcent Stable or trancient elevation of BPStable or trancient elevation of BP

II stageII stageComplaintsComplaints headacheheadache DizzinessDizziness Pain in heart regionPain in heart region Exertional dyspnoeaExertional dyspnoea Presence of hpertonic crisesPresence of hpertonic crises Data of obyective examinationData of obyective examination : : rddness of skin, sweatingrddness of skin, sweating, , decreased decreased

tolerance to physical loadtolerance to physical load.. PalpationPalpation: : PsPs – – firm and tensefirm and tense, , fastfast. . AApex beatpex beat is is expanded and expanded and

displaced leftward and downwarddisplaced leftward and downward.. PercussionPercussion: : widened vascular bundle, displacement of the left border of widened vascular bundle, displacement of the left border of

relative cardiac dullnessrelative cardiac dullness.. AuscultationAuscultation: : The second heart sound is accentuated over the aorta. The second heart sound is accentuated over the aorta.

Systolic murmur over heart apexSystolic murmur over heart apex

There are signs of internal ograns without functional disordersThere are signs of internal ograns without functional disorders:: Hypertrophty of the left ventricle (according to data of ECG and X-ray, Hypertrophty of the left ventricle (according to data of ECG and X-ray,

ultrasound examination)ultrasound examination).. Generalized or focal narrowing of retinal vesselsGeneralized or focal narrowing of retinal vessels.. MicroalbumiuriaMicroalbumiuria, , proteinuria andproteinuria and//ormild elevation of blood plasma creatininormild elevation of blood plasma creatinin

((up toup to 177 177 mkmmkm//ll).).

III stageIII stageHighHigh, , stable elevation of BPstable elevation of BPDevelopment of complicationsDevelopment of complications::- Myocardial infarctionMyocardial infarction- Heart failureHeart failure- InsultInsult- Trancient ischemic attackTrancient ischemic attack- Retinal hemorrhageRetinal hemorrhage- Dissecting aortic aneurismDissecting aortic aneurism

ECGECGІ І stst. – . – specific signs are abcentspecific signs are abcent..ІІ – ІІІ ІІ – ІІІ stst . – . – hypertrophy of the hypertrophy of the

left ventricle, heart electrical left ventricle, heart electrical axis is deviated leftwardaxis is deviated leftward, ,

RvRv5-65-6>Rv>Rv44, , elevation of STelevation of ST, , biphasic biphasic Т (+-)Т (+-)

Increased amplitude of RIncreased amplitude of R in left in left leads and Sleads and S - - in right leadsin right leads..

ECG in hypertrophy of the left ventricleECG in hypertrophy of the left ventricle

Ultrasoung examination of hypertensive heart (B- Ultrasoung examination of hypertensive heart (B- and M-modesand M-modes))

Left-ventricular hypretrophy on Left-ventricular hypretrophy on X-rayX-ray

Symptoms of organs damageSymptoms of organs damage Heart:Heart: palpitations, chest pain, shortness of breath, swollen ankles palpitations, chest pain, shortness of breath, swollen ankles

Brain and eyes:Brain and eyes: headaches, vertigo, impaired vision, TIA’s, sensory or headaches, vertigo, impaired vision, TIA’s, sensory or motor deficitmotor deficit

Kidney:Kidney: thirst, polyuria, nocturia, haematuria thirst, polyuria, nocturia, haematuria

Peripheral arteries:Peripheral arteries: cold extremities, intermittent claudication cold extremities, intermittent claudication Brain: Brain: murmurs over neck arteries, motor or sensory deficitsmurmurs over neck arteries, motor or sensory deficits

Eyes:Eyes: funduscopic abnormalities funduscopic abnormalities

Heart:Heart: location and characteristics of apical impulse, abnormal cardiac location and characteristics of apical impulse, abnormal cardiac rhythms, ventricular gallop, pulmonary rales, peripheral oedemarhythms, ventricular gallop, pulmonary rales, peripheral oedema

Peripheral arteries:Peripheral arteries: absence, reduction, or asymmetry of pulses, cold absence, reduction, or asymmetry of pulses, cold extremities, ischaemic skin lesionsextremities, ischaemic skin lesions

ComplicationsComplications

Дослідження очного днаДослідження очного дна

HYPERTENSIVE RETINOPATHYHYPERTENSIVE RETINOPATHY I degree: Arteriolar I degree: Arteriolar

thickening, tortuosity thickening, tortuosity and increased and increased reflectiveness ('silver reflectiveness ('silver wiring') II degree: plus wiring') II degree: plus constriction of veins at constriction of veins at arterial crossings arterial crossings ('arteriovenous nipping') ('arteriovenous nipping') III degree: plus evidence III degree: plus evidence of retinal ischaemia of retinal ischaemia (flame-shaped or blot (flame-shaped or blot haemorrhages and haemorrhages and 'cotton wool' exudates) 'cotton wool' exudates) IV degree: plus IV degree: plus papilloedema papilloedema

Hypertensive retinopatyHypertensive retinopaty

HeartHeartThe excess cardiac The excess cardiac mortality and mortality and morbidity morbidity associated with associated with

Hypertension. Hypertension. Severe hypertension Severe hypertension can cause left can cause left ventricular failure in ventricular failure in the absence of the absence of coronary artery coronary artery diseasedisease

Atrial fibrillation Atrial fibrillation

Secondary hypertensionSecondary hypertension CAUSES OF SECONDARY HYPERTENSIONCAUSES OF SECONDARY HYPERTENSION

AlcoholAlcohol Pregnancy (pre-eclampsia)Pregnancy (pre-eclampsia) Renal disease Renal disease • • Renal vascular diseaseRenal vascular disease • • Parenchymal renal Parenchymal renal

disease, particularly disease, particularly glomerulonephritisglomerulonephritis

• • Polycystic kidney diseasePolycystic kidney disease Endocrine disease Endocrine disease PhaeochromocytomaPhaeochromocytoma

Cushing's syndromeCushing's syndrome Primary Primary

hyperaldosteronism hyperaldosteronism (Conn's syndrome)(Conn's syndrome)

HyperparathyroidismHyperparathyroidism AcromegalyAcromegaly Primary hypothyroidismPrimary hypothyroidism ThyrotoxicosisThyrotoxicosis Congenital adrenal Congenital adrenal

hyperplasia due to 11 -p-hyperplasia due to 11 -p-hydroxylase orhydroxylase or

17-hydroxylase deficiency17-hydroxylase deficiency

Differential features of Differential features of symptomatic hypertensionsymptomatic hypertension

Age less thanAge less than 20 20 years or more than years or more than 60; 60; quick elevation of BP and its stable high quick elevation of BP and its stable high

levellevel very high BPvery high BP ( (> 220/120 mm of Hg)> 220/120 mm of Hg);; - - malignant course of hypertensionmalignant course of hypertension;; - - sympathoadrenal crisessympathoadrenal crisesееss;; - - renal diseases in anamnesisrenal diseases in anamnesis;; - - development of hypertension during development of hypertension during

pregnancypregnancy;; - - appearance of changes in patient’s urineappearance of changes in patient’s urine..

Complications of hypertonic Complications of hypertonic crisiscrisis

CardialCardial:: - - acute or chronic heart failureacute or chronic heart failure;; - - accelerated development of atherosclerosis accelerated development of atherosclerosis

of caoronary arteries followed by symptoms of caoronary arteries followed by symptoms of angina pectoris and myocardial infarctionof angina pectoris and myocardial infarction;;

- - arrhythmiasarrhythmias.. AortalAortal:: - - atherosclerosis atherosclerosis ;; - - dissecting aortal aneurismdissecting aortal aneurism..

CerebralCerebral:: - - atherosclerosis of atherosclerosis of cerebral vessels and cerebral vessels and impaired cerebral impaired cerebral circulationcirculation ((encephalopathyencephalopathy);); - - dynamic and organic dynamic and organic disorders of brain disorders of brain circulationcirculation і органічні і органічніOcularOcular:: - - retinal hemorrhage retinal hemorrhage and its separationand its separation;; - - decreased visiondecreased vision ((edema of ophthalmic edema of ophthalmic nervenerve))..

TreatmentTreatmentModification of life-styleModification of life-style

DietDiet ( (Decreased salt intake Decreased salt intake to to 4-6 4-6 gg//dayday, , alkoholalkohol,, animal fatsanimal fats).).

Decreased body weightDecreased body weight.. Avoiding of smokingAvoiding of smoking.. Dynamical physical Dynamical physical

examinationsexaminations.. PhytotherapyPhytotherapy, ,

acopunctureacopuncture, , psychtherapypsychtherapy, , authotreningauthotrening

Influence of modification of Influence of modification of life-style of the course of the life-style of the course of the disease:disease:

Decreased body weight - 5-Decreased body weight - 5-20 mm of Hg/10 kg of lost 20 mm of Hg/10 kg of lost weightweight

Diet – 8-14 mm of Hg Diet – 8-14 mm of Hg Decreased salt intake (6 g Decreased salt intake (6 g

per day) – 2-8 mm of Hgper day) – 2-8 mm of Hg Physical activity (30 min Physical activity (30 min

per day) – 4-9 mm of Hgper day) – 4-9 mm of Hg Decreased alkohol Decreased alkohol

consumption (to 1 ounce consumption (to 1 ounce per day) – 2-4 mm of Hgper day) – 2-4 mm of Hg

Scheme of action of hypotensive Scheme of action of hypotensive drugs drugs

Main groups of hypertensive Main groups of hypertensive drugsdrugs

DiureticsDiuretics --blockersblockers Ca- channels antagonistsCa- channels antagonistsAngiotensine-converting enzyme Angiotensine-converting enzyme

inhibitorsinhibitors Blockers of angiotensine-II receptorsBlockers of angiotensine-II receptorsάά1-1-adrenoblochersadrenoblochers

* Not indicated as first line therapy over 60

Dual Combination

Triple or Quadruple Therapy

Lifestyle modificationtherapy

Thiazidediuretic ACE-I Long-acting

CCBBeta-

blocker* ARB

TARGET <140 mm Hg systolic and < 90 mmHg diastolic